Using Forum Theater as a Teaching Tool to Combat Patient Bias Directed Toward Health Care Professionals

An integrative review of the impact of allied health student placements on current staff's knowledge and procedural skills in acute and primary care settings

BACKGROUND

Staff shortages limit access to health services. The bidirectional benefits of allied health clinical placements are understood in the domains of student learning, health service delivery, and future workforce development. Still, the benefits to current workforce outcomes remain unknown. This review provides insights into the effects of allied health student placements in acute and primary care settings, particularly on healthcare staff's knowledge and procedural skills.

METHODS

This search was based on the integrative review process established by Whittemore and Knafl in 2005. In October 2023, the first author (MH) searched five major electronic databases: Medline-EBSCO, PubMed, CINAHL, Embase, and Scopus. The CLUSTER model was used to track additional references. The first three authors (MH, SM, and SC) were involved in screening, quality appraisal, and synthesis of the studies. Data were thematically synthesised and analysed.

RESULTS

MeSH headings and keywords were used in key search areas: health education, health professional training, clinical placements, and allied health professions. The systematic search yielded 12 papers on allied health student placements across various healthcare settings in rural and metropolitan areas, with no high-quality methodologies measuring student placements' impact on staff knowledge and skills. Four main themes were identified from the analysis: meaningful student integration in service delivery, targeted educational support to healthcare staff, development of staff procedural skills and confidence, and the mechanisms of why student placements work in this aspect.

CONCLUSIONS

This review suggests that offering allied health student placement could be a promising approach to supporting rural healthcare staff in performing patient assessments and treatments proficiently and collaboratively. However, this requires further investigation to confirm.

Implicit bias instruction across disciplines related to the social determinants of health: a scoping review

One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.

Forum Theatre to Address Peer-to-Peer Mistreatment in General Surgery Residency

OBJECTIVE

Mistreatment is widespread in graduate medical education, and much attention has been generated on this topic and its relationship to burnout in general surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma - as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solving difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreatment in a surgery residency. FT starts with the performance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the situation ending in a collective solution.

DESIGN

Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the residents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, corrective feedback with the understanding this would be presented to the residency at large. Following this, they developed a scenario for enactment which was implemented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situation until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered.

SETTING

General surgery residency at University of Texas Health San Antonio.

PARTICIPANTS

General surgery residents. 32 of 66 (48.5%) residents participated.

RESULTS

Participants noted an improved understanding of mistreatment, felt more confident in recognizing mistreatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to recognize when they themselves were involved in mistreatment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended participating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professionalism. These trends remained steady in the survey 6 months after the intervention as well.

CONCLUSIONS

We found FT was feasible to implement in a busy general surgery residency and well received with sustained, self- reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT interventions can be tailored to the local culture to address conflicts specific to that setting.

Forum theatre for training residents to be allies

BACKGROUND

Residents are commonly targets and bystanders of workplace discrimination, yet little is known about how best to train residents to manage these incidents. We sought to train residents to respond effectively to being a target or bystander of discrimination.

APPROACH

We used a novel, 75-min theatrical role-playing intervention called Theatre for Healthcare Equity (T.H.E.) to teach 71 internal medicine residents between December 2017 and February 2018. In T.H.E. residents took turns acting as either a 'resident' target or a 'student' bystander in a simulated scenario of discrimination. A facilitator led follow-up discussions including group reflection and development of learning scripts to help with difficult situations. A post-graduation survey was sent in November 2021 to assess residents' retention of knowledge, attitudes and potential application in practice.

EVALUATION

T.H.E. was well received by residents, though survey response rates were low. All respondents to a post-session survey reported having acquired knowledge and skills to help them respond to incidents of bias and discrimination. Most respondents to the post-graduation survey nearly 4 years later remembered T.H.E.; seven wrote reflective narrative responses indicating that T.H.E. had raised awareness of these issues, empowered them to speak up on behalf of colleagues and validated their emotional reactions to hurtful speech from patients. We describe an incident in which a former resident attributed his ability to serve as an effective bystander ally to participating in T.H.E. years earlier.

IMPLICATIONS

T.H.E. was an efficient, well-received intervention that some of our residents found to have been helpful years later. We continue to use T.H.E. as the basis for periodic ongoing allyship training for residents and teaching faculty to improve the inclusiveness of our clinical learning environment.

Theater for Vaccine Hesitancy-Setting the Stage for Difficult Conversations

This Arts and Medicine feature describes use of improvisational theatre techniques to train health care workers to have persuasive and respectful conversations with vaccine-hesitant patients about accepting COVID-19 vaccination.

Tackling Oppressive Beliefs and Sexual Violence on College Campuses: Evaluation of an Innovative Theater-Based Intervention

BACKGROUND

Sexual violence (SV) prevalence remains high among U.S. college campuses; prevention strategies may benefit from addressing socially oppressive beliefs, including racism, sexism, and heterosexism that all directly link to attitudes and beliefs related to SV.

AIMS

The objective of this study is to evaluate the potential efficacy of a novel student-driven, theater-based intervention in shifting beliefs regarding racism, heterosexism, and SV.

METHOD

Data were utilized from paired pre- and posttest surveys (n = 272) from undergraduate students, at a university in the Southeastern United States, who attended a student-driven theater production covering topics of SV, heterosexism, and racism. The survey included questions on rape myth acceptance, heteronormative attitudes and beliefs, perceived racism on campus, and relevant respondent demographic information.

RESULTS

After viewing the theater production, participants demonstrated significant decreases pretest-posttest in rape myth acceptance, (ΔM = 0.04, SD = 0.25), t(261) = 2.57, p = .01, heteronormative attitudes and beliefs, (ΔM = 0.09, SD = 0.36), t(267) = 3.32, p = .0001, and an increased pretest-posttest in perceived racism on campus, (ΔM = -0.15, SD = 0.47), t(266) = -5.15, p < .0001. For rape myth acceptance and heteronormative attitudes and beliefs, no apparent differences were present by race, gender identity, sexual orientation, or year in school. Only White and mixed-race students' levels of perceived prevalence racism increased when examined by race.

IMPLICATIONS

Findings from this study suggest that theater interventions may not only be an effective tool for addressing SV on campus, but also targeting other forms of discrimination, including sexism, homophobia, and racism among students.

Mistreatment in Residency: Intervening With the REWIND Communication Tool

INTRODUCTION

There is a lack of curricula addressing the alarming rates of resident physician mistreatment. As the ACGME works to address diversity, equity, and inclusion in GME, there has been increasing attention paid to the issue of mistreatment. Previous studies have noted a high prevalence of mistreatment within GME. Despite this, there are few published interventions to address the mistreatment of residents. We developed a workshop for residents to provide an overview of mistreatment in residency and teach them REWIND (relax, express, why, inquire, negotiate, determine), a communication tool to address mistreatment directly.

METHODS

We designed a 60-minute workshop for residents with didactics on mistreatment in GME, followed by three case discussions. Four case scenarios were developed to represent different types of mistreatment and situations. We implemented the workshop twice and asked participants to self-rate proficiency around the workshop objectives with pre- and postsurveys.

RESULTS

A total of 11 GME learners completed both the pre- and postsurveys between the two workshop implementations. GME learners who responded demonstrated significantly higher self-rated proficiency on each objective postworkshop compared to preworkshop (p < .05). Free responses on the survey demonstrated that participants particularly enjoyed the case discussions and wanted more practice with REWIND.

DISCUSSION

Our workshop improved participant self-rated proficiency around the mistreatment of resident physicians. The workshop can be used in the future as part of a multifaceted institutional response to mistreatment.